Prednisone, the Dirty Little Secret, Becomes More Respectable

Many rheumatologists at least verbalize a reluctance to use “cortisone”-like drugs such as prednisone in the treatment of rheumatoid arthritis; but many, if not most, rheumatologists do use prednisone. Prednisone, even in low dosages, can cause high blood sugar, cardiovascular disease, weight gain, and osteoporosis. And prednisone may also contribute to increased infection risk, hypertension, depression, cataracts, and peptic ulcer disease.

But prednisone is an excellent anti-inflammatory, and it has been conclusively shown that low dosages of prednisone decrease bone damage due to rheumatoid arthritis. Patients report decreased joint swelling and tenderness, and researchers have noted a slowing in the progression of rheumatoid arthritis.

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Medications such as prednisone enter cells and bind to a receptor. This decreases biochemicals which produce inflammation, in as little a dose as 7.5mg of prednisone. Prednisone can also replace the body’s natural “cortisone,” which is normally produced by the body and which can be diminished by the damaging inflammation of rheumatoid arthritis.

A recent systematic review of studies looking at prednisone and its usefulness in rheumatoid arthritis was performed by researchers for the Cochrane Database of Systematic Reviews. Fifteen studies which looked chiefly at disease duration of two years or less were included in the analysis; all studies showed a treatment benefit with prednisone or drugs similar to prednisone, and these benefits were generally achieved when combined with other disease modifying drugs such as methotrexate. The authors of the review concluded that the evidence was very strong that a drug such as prednisone given along with a drug such as methotrexate can significantly reduce the joint/bone destruction seen in rheumatoid arthritis.

This review of studies also suggested that patients who have had rheumatoid arthritis for less than two years appear to have less chance of joint destruction if their doctors begin them on prednisone at the time of their diagnosis, even if the prednisone is eventually tapered down significantly.

Unfortunately, there was not enough data to be able to conclude whether or not patients who have had rheumatoid arthritis for several years would also benefit from the use of prednisone, as was shown for those who have had rheumatoid arthritis for two years or less.

Interestingly, the question naturally arises, would the consistent early use of prednisone in addition to the more traditional disease modifying drugs (such as methotrexate) be just as beneficial—and with the same or less risk—as the newer and much more expensive drugs such as Humira, Remicade, Enbrel, Rituxan, and Orencia? Only head-to-head studies can answer this question. Whether we will see such studies remains a whole other ball game…